Child Immunization Coverage in Urban Settings of Twelve Provinces Plus Kabul, Afghanistan, 2019

"...findings shed light on the status of immunization coverage and highlight important factors influencing parents' decisions regarding vaccination."

Afghanistan has low immunisation coverage and endemic polio, with the risk for polio virus transmission triggered due to its proximity to neighbouring Pakistan, another polio-endemic country. In this context, the objective of this study was to estimate the coverage of immunisation status among children of 12-23 months in urban settings of 12 high-risk provinces for polio plus Kabul, Afghanistan, in 2019.

A 2-stage cluster sampling was used to approach 30 clusters and interview 7 households. Participants included 3,382 caregivers of children aged 12-23 months, about half of whom were boys. The literacy of mothers was 35%, and 86.4% were housewives with no formal employment. Coverage for 13 vaccines against 10 childhood diseases prioritised by the Afghanistan Immunization programme was assessed through observation of vaccine cards or by history from the caregivers.

In total, 1,261 (37.29%) children were fully vaccinated, which is very far from the target of 80%. In addition, 833 (54.2%) were partially vaccinated, and 288 (8.52%) did not receive any dose of routine vaccine. In total, 71.82% had vaccination cards, 17.24% had lost them, and 11% had no cards. Coverage of immunisation by cards and history was 91.70% for Bacillus Calmette-Guérin (BCG), 52% for Pentavalent vaccine, 78% for oral polio vaccine (OPV4), 63% for pneumococcal conjugate vaccine (PCV2), 61% for rotavirus vaccine (dose 2), 68.50% for measles (dose 1), and 58% for inactivated polio vaccine (IPV). These results underscore the need for focused efforts to improve immunisation coverage and ensure that all children receive the recommended vaccines.

In addition to assessing the rates of immunisation coverage, this study delved into the factors influencing parents' decisions regarding full, partial, or nonvaccination of their children. Among those who reported fully vaccinating their children, the most cited reason was a recognition of the crucial importance of vaccination, with 54.71% of respondents acknowledging this factor. Other motivating factors included the convenience of proximity to a healthcare facility offering vaccines (7.78%) and the effective outreach efforts of vaccination programmes (1.82%). Furthermore, a positive interaction with vaccinators was mentioned by some parents as a contributing factor to their decision to vaccinate their children (1.74%).

Parents or caretakers of partially vaccinated children reported the presence of various factors contributing to incomplete vaccination. Among this group, approximately 14% of individuals cited lack of awareness as a significant reason for partial vaccination. In addition, 13% of caregivers expressed a lack of time as a substantial barrier in completing their children's vaccination schedule. Furthermore, a notable 10% of respondents mentioned losing their child's vaccination card as a factor contributing to incomplete vaccination. Some other factors, such as insecurity of accessing health facilities for vaccination and wide time gaps between vaccinations, were reported as well.

From the total of 288 unvaccinated children's primary caretakers, the most prevalent factor, accounting for 34%, was the presence of misconceptions and incorrect ideas about vaccines. Such misconceptions were mainly fear of infertility among children after being vaccinated. In addition, respondents also believed that vaccines are haram (prohibited in Islam). Following closely behind was the occupational engagement of mothers, with 26% of respondents citing this as a contributing factor. Immigration also accounted for 22% of the caretakers'/parents' reasons for not taking vaccines. In addition, 22% expressed fear of vaccine side effects, while 13% mentioned hearing false rumours as influencing their decision. Respondents reported hearing the rumour that vaccines are overseas' products that are being administered to Afghans as part of their conspiracy towards Afghanistan; such rumours eventually affected and influenced their decision. Caretakers also reported familial restrictions: the father, grandfather, and close family relatives not giving the permission to vaccinate the children.

In the context of the study's findings, the researchers argue that a multifaceted approach is imperative to enhance children's immunisation coverage in Afghanistan. For example, there is a need for:
 

• The identification and rectification of misconceptions that influence vaccination decisions - The study underscored the importance of tailored education campaigns designed to counteract these misconceptions and enhance public understanding of the manifold benefits that immunisation confers.
• Research endeavors that probe deeper into the dynamics of vaccine hesitancy and the specific concerns held by parents and caretakers in Afghanistan - These studies could provide insights into the underlying causes of hesitancy, thereby serving as a foundation for tailored interventions to bolster confidence in immunisation.
• A targeted focus on policy implementation and outreach strategies, particularly in urban areas, to ensure that vaccination services are universally accessible - These efforts should be geared towards achieving equitable immunisation coverage across diverse demographic groups, thereby mitigating disparities in vaccination rates.
• Investment in the augmentation of healthcare infrastructure, with a particular emphasis on urban regions - The expansion and fortification of clinics, vaccination centres, and outreach programmes can facilitate improved access to vaccination services.
• A robust system of monitoring and evaluation to continuously track the progress of vaccination programmes - This ongoing assessment will identify emerging challenges and adapting strategies to address them effectively.
• An expanded scope of research to encompass maternal immunisation coverage.
   

Thus, in light of the fact that child immunisation levels, varying across cities, were suboptimal in the study population, the study recommends setting realistic targets to achieve optimal vaccination coverage and conducting awareness campaigns to enhance vaccination coverage, decrease dropout rates, and address reasons for partial or no immunisation.